Michele Salati

Peak Oxygen Consumption During Cardiopulmonary Exercise Test Improves Risk Stratification in Candidates to Major Lung Resection

BACKGROUND The objective of this investigation was to assess the association of peak oxygen consumption (Vo(2)) with postoperative outcome in a prospective cohort of patients undergoing major lung resection for the treatment of lung cancer. METHODS Preoperative symptom-limited cardiopulmonary exercise testing (CPET) performed using cycle ergometry was conducted in 204 consecutive patients who had undergone pulmonary lobectomy or pneumonectomy. Peak Vo(2) was tested for possible association with postoperative cardiopulmonary complications and mortality. Logistic regression analysis, validated by a bootstrap analysis, was used to adjust for the effect of other perioperative factors. The role of peak Vo(2) in stratifying the surgical risk was further assessed in different groups of patients subdivided according to their cardiorespiratory status. RESULTS Logistic regression showed that peak Vo(2) was an independent and reliable predictor of pulmonary complications (p = 0.04). All six deaths occurred in patients with a peak Vo(2) of < 20 mL/kg/min (four deaths in patients with a peak Vo(2) of < 12 mL/kg/min). The mortality rate in this high-risk group was 10-fold higher (4 of 30 patients; 13%) compared to those with higher peak Vo(2) (p = 0.006). Compared to patients with a peak Vo(2) of > 20 mL/kg/min, those with a peak Vo(2) of < 12 mL/kg/min had 5-fold, 8-fold, 5-fold, and 13-fold higher rates, respectively, of total cardiopulmonary complications pulmonary complications, cardiac complications, and mortality. CONCLUSIONS The present study supports a more liberal use of CPET before lung resection compared to the current guidelines since this test can help in stratifying the surgical risk and optimizing perioperative care.

Evaluation of a new chest tube removal protocol using digital air leak monitoring after lobectomy: a prospective randomised trial

BACKGROUND The objective of this randomised trial was to assess the effectiveness of a new fast-track chest tube removal protocol taking advantage of digital monitoring of air leak compared to a traditional protocol using visual and subjective assessment of air leak (bubbles). METHODS One hundred and sixty-six patients submitted to pulmonary lobectomy for lung cancer were randomised in two groups with different chest tube removal protocols: (1) in the new protocol, chest tube was removed based on digitally recorded measurements of air leak flow; (2) in the traditional protocol, the chest tube removal was based on an instantaneous assessment of air leak during daily rounds. The two groups were compared in terms of chest tube duration, hospital stay and costs. RESULTS The two groups were well matched for several preoperative and operative variables. Compared to the traditional protocol, the new digital recording protocol showed mean reductions in chest tube duration (p=0.0007), hospital stay (p=0.007) of 0.9 day, and a mean cost saving of euro 476 per patient (p=0.008). In the new chest tube removal protocol, 51% of patients had their chest tube removed by the second postoperative day versus only 12% of those in the traditional protocol. CONCLUSIONS The application of a chest tube removal protocol using a digital drainage unit featuring a continuous recording of air leak was safe and cost effective. Although future studies are warranted to confirm these results in other settings, the use of this new protocol is now routinely applied in our practice.

Recalibration of the Revised Cardiac Risk Index in Lung Resection Candidates

BACKGROUND The revised cardiac risk index (RCRI) has been proposed as a tool for cardiac risk stratification before lung resection. However, the RCRI was originally developed from a generic surgical population including a small group of thoracic patients. The objective of this study was to recalibrate the RCRI in candidates for major lung resections to provide a more specific instrument for cardiac risk stratification. METHODS One thousand six hundred ninety-six patients who underwent lobectomy (1,426) or pneumonectomy (270) in two centers between the years of 2000 and 2008 were analyzed. Stepwise logistic regression and bootstrap analyses were used to recalibrate the six variables comprising the RCRI. The outcome variable was occurrence of major cardiac complications (cardiac arrest, complete heart block, acute myocardial infarction, pulmonary edema, or cardiac death during admission). Only those variables with a probability of less than 0.1 in more than 50% of bootstrap samples were retained in the final model and proportionally weighted according to their regression estimates. RESULTS The incidence of major cardiac morbidity was 3.3% (57 patients). Four of the six variables present in the RCRI were reliably associated with major cardiac complications: cerebrovascular disease (1.5 points), cardiac ischemia (1.5 points), renal disease (1 point), and pneumonectomy (1.5 points). Patients were grouped into four classes according to their recalibrated RCRI, predicting an incremental risk of cardiac morbidity (p < 0.0001). Compared with the traditional RCRI, the recalibrated score had a higher discrimination (c indexes, 0.72 versus 0.62; p = 0.004). CONCLUSIONS The recalibrated RCRI can be reliably used as a first-line screening instrument during cardiologic risk stratification for selecting those patients needing further cardiologic testing from those who can proceed with pulmonary evaluation without any further cardiac tests.

Pleural tent after upper lobectomy: a randomized study of efficacy and duration of effect

BACKGROUND The object of this study was to assess the efficay and maximum duration of effect of the pleural tent in reducing the incidence of air leak after upper lobectomy. METHODS Two hundred patients who underwent upper lobectomy were prospectively randomized into two groups: 100 patients who underwent an upper lobectomy and a pleural tent procedure (group 1; tented patients) and 100 patients who underwent only an upper lobectomy and not a pleural tent procedure (group 2; untented patients). The preoperative, operative, and postoperative characteristics of both groups were compared. Then multivariate analyses were used to identify factors predictive of prolonged air leaks and their duration. The reduction of incidences of air leak in the two groups was subsequently compared during successive postoperative periods. RESULTS No differences were detected between the two groups in terms of preoperative and operative characteristics. A significant reduction occurred in group 1 patients for the mean duration of air leak in days (2.5 vs 7.2 days; p < 0001), the number of days a chest tube was required (7.0 vs 11.2 days; p < 0.0001), the length of postoperative hospital stay in days (8.2 vs 11.6 days; p < 0.0001), and the hospital stay cost per patient (4,110 dollars vs 5,805 dollars; p < 0.0001). Logistic regression analyses showed that not having undergone a pleural tent procedure was the most significant predictive factor of the occurrence and duration of prolonged air leaks. A greater reduction in the duration of air leaks was observed before postoperative day 4 in group 1, and logistic regression analysis showed that having undergone a pleural tent procedure was the most significant predictive factor of air leaks that persisted for less than 4 days. CONCLUSIONS Pleural tenting after upper lobectomy was a safe procedure that reduced the duration of air leaks and the hospital stay costs. The benefit from that procedure was achieved before postoperative day 4.

The Society of Thoracic Surgeons and The European Society of Thoracic Surgeons General Thoracic Surgery Databases: Joint Standardization of Variable Definitions and Terminology

The European Society of Thoracic Surgery (ESTS) and the Society of Thoracic Surgeons (STS) general thoracic surgery databases collect thoracic surgical data from Europe and North America, respectively. Their objectives are similar: to measure processes and outcomes so as to improve the quality of thoracic surgical care. Future collaboration between the two databases and their integration could generate significant new knowledge. However, important discrepancies exist in terminology and definitions between the two databases. The objective of this collaboration between the ESTS and STS is to identify important differences between databases and harmonize terminology and definitions to facilitate future endeavors.

Quality of life in the elderly after major lung resection for lung cancer

The objective of this study was to assess the residual quality of life (QoL) in elderly patients submitted to major lung resection for lung cancer. From July 2004 through August 2007 a total of 218 patients, 85 of whom were elderly (70 years), had complete preoperative and postoperative (3 months) quality of life measures assessed by the Short Form 36v2 health survey. QoL scales were compared between elderly and younger patients. Furthermore, limited to the elderly group, we compared the preoperative with the postoperative SF36v2 measures and the physical component summary (PCS) and mental component summary (MCS) scores between high-risk patients and low-risk counterparts. The postoperative SF36 PCS (50.3 vs. 50, P=0.7) and MCS (50.6 vs. 49, P=0.2) and all SF36 domains did not differ between elderly and younger patients. Within the elderly, the QoL returns to the preoperative values three months after the operation. Moreover, we did not find any significant differences between elderly higher-risk patients and their lower-risk counterparts postoperatively. The information that residual QoL in elderly patients will be similar to the one experienced by younger and fitter individuals may help them in their decision to proceed with surgery.

Uniportal Video-Assisted Thoracic Surgery for Diagnosis and Treatment of Intrathoracic Conditions

The effort to reduce the invasiveness of thoracic surgery is increasing in this specialty. In this context, preliminary evidence has shown that uniportal video-assisted thoracic surgery represents a valuable option to perform different diagnostic and curative procedures. This article addresses the topic of uniportal video-assisted thoracic surgery as the least invasive such approach that may be used to diagnose and treat several intrathoracic conditions.

Performance at Preoperative Stair-Climbing Test Is Associated With Prognosis After Pulmonary Resection in Stage I Non-Small Cell Lung Cancer

BACKGROUND This investigation evaluated whether the performance at a preoperative symptom-limited stair-climbing test was a prognostic factor in resected pathologic stage I non-small cell lung cancer (NSCLC). METHODS Observational analysis was performed on a prospective database that included 296 patients who underwent pulmonary lobectomy for pathologic stage T1 N0 or T2 N0 NSCLC (2000 to 2008). Patients who received induction chemotherapy were excluded. Survival was calculated by the Kaplan-Meyer method. The log-rank test was used to assess differences in survival between groups. The relationships between survival and baseline and clinical variables were determined by Cox multivariate analyses. RESULTS Median follow-up was 43 months. The best cutoff associated with prognosis was an 18-meter stair climb. Median (months) survival and 5-year survival of patients who climbed more than 18 meters were significantly longer than those who climbed less than 18 meters (97 vs 74; 77% vs 54%, p=0.001). Cox regression model (hazard ratio) showed that climbing more than 18 meters (0.5; p=0.003), diffusion capacity of the lung for carbon monoxide (0.98; p=0.02), and pT stage (1.8; p=0.02) were independent prognostic factors. Patients who climbed less than 18 meters had increased deaths from cancer (24% vs 15%, p=0.1) or other causes (19% vs 9%, p=0.02). CONCLUSIONS Preoperative cardiopulmonary fitness is a significant prognostic factor in patients after resection for early-stage NSCLC. Interventions aimed at improving exercise tolerance can be useful to improve long-term prognosis after NSCLC operations.

Minute Ventilation-to-Carbon Dioxide Output ( V ˙e/ V ˙co2) Slope Is the Strongest Predictor of Respiratory Complications and Death After Pulmonary Resection

BACKGROUND This study assessed whether the minute ventilation-to-carbon dioxide output (VE/VCO2) slope, a measure of ventilatory efficiency routinely measured during cardiopulmonary exercise testing (CPET), is an independent predictor of respiratory complications after major lung resections. METHODS Prospective observational analysis was performed on 225 consecutive candidates after lobectomy (197 patients) or pneumonectomy (28 patients) from 2008 to 2010. Inoperability criteria were peak oxygen consumption (VO2) of less than 10 mL/kg/min in association with predicted postoperative forced expiratory volume in 1 second of less than 30% and diffusion capacity of the lung for carbon monoxide of less than 30%. All patients performed a symptom-limited CPET on cycle ergometer. Respiratory complications (30 days or in-hospital) were prospectively recorded: pneumonia, atelectasis requiring bronchoscopy, respiratory failure on mechanical ventilation exceeding 48 hours, adult respiratory distress syndrome, pulmonary edema, and pulmonary embolism. Univariable and multivariable regression analyses were used to identify independent predictors of respiratory complications. RESULTS Cardiopulmonary morbidity and mortality rates were 23% (51 patients) and 2.2% (5 patients). The 25 patients with respiratory complications had a significantly higher VE/VCO2 slope than those without complications (34.8 vs 30.9, p=0.001). Peak VO2 was not associated with respiratory complications. Logistic regression and bootstrap analyses showed that, after adjusting for other baseline and perioperative variables, the strongest predictor of respiratory complications was VE/VCO2 slope (regression coefficient, 0.09; bootstrap frequency, 89%; p=0.004). Patients with a VE/VCO2 slope exceeding 35 had a higher incidence of respiratory complications (22% vs 7.6%, p=0.004) and mortality (7.2% vs. 0.6%, p=0.01). CONCLUSIONS VE/VCO2 slope is a better predictor of respiratory complications than peak VO2. This inexpensive and operator-independent variable should be considered in the clinical practice to refine operability selection criteria.

Digital measurements of air leak flow and intrapleural pressures in the immediate postoperative period predict risk of prolonged air leak after pulmonary lobectomy

BACKGROUND The objective of this prospective observational study was to evaluate the association between the airflow and intrapleural pressures digitally recorded during the immediate postoperative period after lobectomy and their ability to predict the risk of subsequent prolonged air leak (PAL). METHODS A total of 145 consecutive patients underwent pulmonary lobectomy in two centers. All patients were managed with the chest tube placed on suction (-20 cm H(2)O) until the morning of the first postoperative day. Measurement of airflow and maximum and minimum intrapleural pressures were recorded during the 6th postoperative hour using a digital chest drainage device. Logistic regression analysis validated by bootstrap was used to test independent association of variables with PAL (air leak>72 h). RESULTS The mean air leak flow at the 6th postoperative hour was 86 ml min(-1) (0-1100 ml min(-1)). The mean maximum and minimum pleural pressures at the 6th postoperative hour were -11.4 cm H(2)O and -21.9 cm H(2)O, respectively. Logistic regression and bootstrap showed that the mean air leak flow (p=0.007) and the mean differential pleural pressure (ΔP: maximum-minimum intrapleural pressure) (p=0.02) at the 6th postoperative hour were reliably associated with PAL, independent of the effect of age, forced expiratory volume 1 (FEV1), chronic obstructive pulmonary disease (COPD) status, diffusing capacity of the lung for carbon monoxide (DLCO), side, and site of lobectomy. According to best cutoffs derived by receiver operating characteristic (ROC) analysis the following combinations showed incremental risk of PAL: ΔP<10+Flow<50: 4% (3/73); ΔP>10+Flow<50: 15% (5/33); ΔP<10+Flow>50: 36% (5/14); ΔP>10+Flow>50: 52% (13/25). CONCLUSIONS The levels of both air leak flow and pleural pressure measured at the 6th postoperative hour are associated to a different extent with the duration of air leak. Interpretation of the data measured at an early time point by digital chest drainage systems allows estimation of the risk of subsequent PAL. In this way, digital devices may help to plan postoperative management to allow both safe and more accurate implementation of fast-tracking strategies.